Snapshot A 36-year-old man presents in the clinic with persistent right jaw swelling following a tooth extraction six weeks earlier. Patient reports a yellow discharge draining from the swelling. He denies pain, fever, or weight loss. He is a known diabetic. Physical exam shows a right submandibular mass, about four by four centimeters with a sinus tract draining yellow granules. Routine blood tests were normal. PPD was non-reactive. CT scan of the head and neck was normal. Gram stain of the discharge revealed sulfur granules with branching gram-positive filaments. Introduction Classification bacteria fungus-like bacteria Actinomyces A. isrealii Presentation Eroding abscesses of the mouth or GI tract drainage from abscesses contains microscopic yellow granules called "sulfur granules" contains bacteria and debris, not sulfur very invasive, although usually not painful Occurs in tissues with low oxygenation jaw due to trauma or poor hygiene pelvis associated with IUD use abdomen thorax CNS can produce solitary brain abscess Nocardia produces multiple foci Evaluation Often mistaken for common bacterial infection of the teeth or jaw Definitive diagnosis via culture histology monoclonal antibody staining Non-acid fast vs. Nocardia which is partially acid fast Differential Osteomyelitis of the jaw Salivary gland tumors TB cervical lymphadenitis Treatment Penicillin G or ampicillin + surgical drainage "SNAP" = Sulfa for Nocardia; Actinomyces use Penicillin Prognosis, Prevention and Complications Prevention maintainance of good oral hygiene avoid use of IUD in women with previous history Complications recalcitrant fibrotic lesions or extensive abscesses require surgery